| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
83 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
43 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$1K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$927.50 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$710.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$612.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$598.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$337.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
22 |
$225.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$127.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$105.00 |